VETERINARY MEDICINE LICENSE APPLICATION INSTRUCTIONS AND INFORMATION

Transcription

1 The Commonwealth of Massachusetts Division of Professional Licensure Board of Registration of Veterinary Medicine 1000 Washington Street, Suite 710 Boston, MA Phone: (617) VETERINARY MEDICINE LICENSE APPLICATION INSTRUCTIONS AND INFORMATION EXAMINATION INFORMATION Only candidates seeking a Massachusetts license will be permitted to sit for the North American Veterinary Licensing Exam (NAVLE) and/or the Jurisprudence examination. Graduates of non- AVMA accredited programs must enroll in either the Educational Commission for Foreign Veterinary Graduates (ECFVG) or the Program for the Assessment of Veterinary Education Equivalence (PAVE) program before applying, and proof of enrollment is required prior to sitting for an examination (See Information for Graduates of Non-AVMA Accredited Veterinary Schools section below). All examination candidates must have either graduated or be within 210 days of graduation (on the date of the examination). The Board will accept a letter from the Dean of a veterinary school which certifies that you have received the degree of Doctor of Veterinary Medicine or have met all of the requirements for graduation and will graduate no later than 210 calendar days after the Board s examination. In lieu of a letter from the dean, completion of item no. 8 on the application is acceptable. Please note that candidates who sit for the examination prior to graduation will be required to submit a notarized copy of their diploma or an official transcript AFTER graduation. Exams are administered during specific windows in the spring and winter. Candidates wishing to sit for the NAVLE must submit this license application and fees to the Board no later than the deadline listed on the enclosed application, AND apply directly to the National Board of Veterinary Medical Examiners (NBVME). Please visit for specifics on NBVME s application process and deadlines for the NAVLE. Please be aware that NAVLE examination fees will be paid directly to NBVME, and are in addition to the fees required to be submitted with this licensure application. Do not wait until the last minute to complete either of these steps, as we cannot be responsible for mail delays. Information received after the deadline will not be accepted. Following review and approval of the application, candidates will be added to the Board's list of approved applicants, which is submitted to NBVME just prior to their registration deadline. Be reminded that All approved candidates are required to ALSO register with NBVME. For exams taken prior to December 1992, the passing grade on the NBE and CCT is 75. Passing status on current national exams is established using a content-based or criterion referenced standard setting procedure. Please visit for more information on the current passing standard. The Board will notify all candidates in writing of their national examination results approximately 6 to 8 weeks following the closing of each testing window. The jurisprudence examination will be scored upon receipt of your application. Please do not call the Board for your results, as they cannot be given over the phone. If you have already successfully completed the national exams, you must have a score report forwarded to the Board. Score transfer requests are processed by the Veterinary Information Verifying Agency (VIVA) of the American Association of Veterinary State Boards (AAVSB). A score transfer

2 request can be processed on-line through the VIVA link on the AAVSB web site, If you choose to mail or fax a request, a VIVA score transfer application form is also available as a pdf file for printing on the website. AAVSB can be reached by phone at (877) JURISPRUDENCE EXAMINATION All applicants are required to pass the Massachusetts Veterinary Jurisprudence Examination. This exam is designed to assess your knowledge of Massachusetts statutes and regulations with regards to the practice of veterinary medicine. This exam must be included when submitting your application for licensure. Please be aware that this examination is not available on-line or via and will be mailed out upon request. Please contact Board staff to obtain a copy of the Massachusetts Jurisprudence Examination {call (617) or Diane.m.savickas@state.ma.us}. RECIPROCITY If you are a licensed veterinarian in another state and have been engaged in the practice of veterinary medicine for five consecutive years, you may apply for licensure in Massachusetts via reciprocity. Reciprocity applicants are required to complete all portions of the application, including the submission of professional references and passage of the Jurisprudence examination. In addition a certified letter of licensure status must be submitted directly from all states in which currently and/or previously licensed, and a score report must be received from VIVA (see instructions above regarding obtaining score transfer). LIMITED LICENSES FOR BOARD CERTIFIED VETERINARIANS The NAVLE requirement may be waived in the case of an AVMA board certified veterinarian (Jurisprudence Exam will not be waived). If such a waiver is granted, the Board shall restrict the licensee s veterinary practice to his/her board specialty. Limited license applicants are required to complete all portions of the application, including the submission of professional references and passage of the Jurisprudence examination. In addition, a current CV/resume and a copy of your board specialty certificate must be submitted. An interview with the Board may also be required. INFORMATION FOR GRADUATES OF NON-AVMA ACCREDITED VETERINARY SCHOOLS The Massachusetts Board of Veterinary Medicine permits graduates of non-avma accredited programs to apply for licensure in Massachusetts and sit for the NAVLE and Jurisprudence examination provided that the following is submitted: 1. Complete licensure application 2. Confirmation of degree from veterinary school {Candidates receiving a degree from a foreign veterinary school must have transcripts or diplomas translated into English and notarized prior to submitting them as evidence of graduation.} 3. Proof of enrollment in the ECFVG or PAVE certification program Please be aware however that following passage of the NAVLE, licensure will not be granted until official documentation of the completion of the ECFVG or PAVE certification program is received by the Board office. Information on the ECFVG certification program can be obtained via their website by mail at American Veterinary Medical Association, ATTN:

3 ECFVG,1931, N. Meacham Road, Suite 100, Schaumburg, IL , or by phone at (800) Information on the PAVE program can be obtained via their website at by mail at The PAVE Program, 380 W. 22nd Street, Suite 101, Kansas City, MO 64108, or by phone at ext TEMPORARY PERMITS {For Graduates of Non-AVMA Accredited Veterinary Schools Only} An applicant who is a graduate of a non-avma accredited veterinary school, who meets the below specified criteria, may apply for a temporary permit to practice veterinary medicine in the Commonwealth. Temporary permits are issued for a period of six months with the possibility of one 6-month renewal. A candidate to whom the Board issues a temporary permit may only practice under the direct supervision of a veterinarian licensed in the Commonwealth. In addition to submitting the completed application, be sure to complete the temporary permit application. To be eligible for a six month temporary permit, a candidate must have passed both the jurisprudence examination and the national exams, and must be within six months of completing the PAVE or ECFVG. A Board interview with the candidate and supervisor is required and will be scheduled following application approval. ALL APPLICANTS The enclosed Professional and Ethical Reference Forms must be completed by currently licensed Veterinarians who are familiar with your veterinary skills, as well as your professional and ethical conduct. You must complete the top portion of the Reference Forms and provide them to the references, who should complete them, have them notarized, and remit them to you in a sealed envelope with their signature across the back. DO NOT SUBMIT UNSEALED OR UNSIGNED REFERENCES. The enclosed checklist must be filled out and submitted to the Board in order for your application to be considered complete. Officially sealed transcripts and other forms to be filled out by a third party (references, letters of licensure standing, etc) may be sent under separate cover, however it is preferred that they be submitted with the application in order to avoid delays. If submitted with the application, those items must remain sealed and your references must sign along the seal on the back of the envelope. Letters of verification from states you currently hold or have held a license must be submitted directly to the Board from that state. All applicants applying for licensure are required to submit official sealed transcripts of the conferred degree or a notarized photocopy of the diploma. Please remember that you are not permitted to practice veterinary medicine in Massachusetts until you have received notification that the Board has granted a license. Application Fees = $ The above noted total application fee is made up of an application processing fee ($117.00) plus a jurisprudence examination fee ($155.00). Both fees which are NON-REFUNDABLE should be paid in one personal check or money order payable to the Commonwealth of Massachusetts. Please do not send cash. *Following review and approval of the application, when it is determined that all licensure requirements have been met an initial licensure fee will then be assessed*

4 The Commonwealth of Massachusetts Division of Professional Licensure Board of Registration of Veterinary Medicine 1000 Washington Street, Suite 710 Boston, MA Phone: (617) Please attach recent passport type 2 x 2 head and shoulder photograph VETERINARY MEDICINE LICENSURE APPLICATION {NON-REFUNDABLE APPLICATION AND JURISPRUDENCE EXAM FEE $272.00} 1. Name: Last First Middle Maiden 2. Mailing Address(this will be public record): No. Street Apt. No. City/Town State Zip Code 3. Date of Birth: Place of Birth: month/ day/ year 4. Telephone Number (Day): (Eve.): 5. address: 6. Name of Veterinary School: 7. Date and Degree Conferred: 8. CERTIFICATE BY DEAN OR REGISTRAR OF VETERINARY COLLEGE (If Requesting Examination Prior to Degree Conferral) I,, as Dean/Registrar of certify that the applicant attended this institution from to and has received or will receive (circle one) a Doctor of Veterinary Medicine degree on. SCHOOL SEAL Signature of Dean/Registrar

5 9. DISCIPLINARY HISTORY If you answer YES to any of the following questions (A-F), please attach a complete explanation. A. Has any disciplinary actions been taken against you by a licensing/certification board located in the United States or any country or foreign jurisdiction? YES NO B. Are you the subject of pending disciplinary action by a licensing/certification board located in the United States or any country or foreign jurisdiction? YES NO C. Have you ever voluntarily surrendered or resigned a professional license to a licensing/certification board in the United States or any country or foreign jurisdiction? YES NO D. Have you ever applied for and been denied a professional license in the United States or any country or foreign jurisdiction? YES NO E. Has your registration/license to dispense controlled substances ever been suspended, revoked, or placed on probation? YES NO F. Have you ever been convicted of a felony or misdemeanor in the United States or any country or foreign jurisdiction, other than a traffic violation for which a fine of less than $ was assessed? YES NO The Board is certified by the Criminal History Systems Board [ID# MAREG G] to access data about convictions and pending criminal cases. Those records-and other Federal and professional records-may be checked as part of your licensing process. No records are automatic disqualifiers; you will be given an opportunity to discuss any issues with the Board. 10. List any professional licenses/registrations you hold or have held in the United States or any country or foreign jurisdiction and the state/jurisdiction from which the license/registration was issued along with the license number. 11. List all addresses where you have engaged in the practice of veterinary medicine, including service in the armed services. 12. If you are presently engaged in any type of veterinary endeavor either as a principal or as an assistant, please provide details. 13. Application Deadlines and NAVLE exam dates: (Please indicate which testing window you are applying for OR that you have already tested.) August 1, 2015 DEADLINE: December 20, 2015 DEADLINE: November 16 December 12, 2015 testing window April 11-23, 2016 testing window Already passed NAVLE

6 14. Have you taken any of the following examinations? NBE CCT Candidates who have successfully taken and passed the NBE and CCT on or before April 2000 are eligible for a license. Candidates who have passed only one of those examinations will be required to take the NAVLE. If you have previously taken an examination, you must have your scores transferred from VIVA to the Board of Veterinary Medicine (See instructions) 15. Pursuant to GL c 62C, s. 49A, I have filed all Massachusetts tax returns and paid all Massachusetts taxes required by law. YES NO if no, please explain (If you have never been a resident of MA and therefore not required to file MA taxes check no and indicate that above) 16. If you are not a graduate of a school of veterinary medicine accredited by the American Veterinary Medical Association, have you secured a PAVE or ECFVG certificate or a Certificate of Qualification issued by the Canadian Veterinary Medical Association? YES NO IN PROCESS N/A Official documentation of certificate status is required from the awarding entity (see instructions) 17. Please list the two licensed veterinarians who will be completing the Professional and Ethical Reference Forms. 18. AFFIDAVIT I certify, that I agree to abide by the GL c. 112, s and the Rules and Regulations for the licensing of veterinarians as contained in 256 CMR and attest that all statements made in herein are truthful and are made under the pains and penalties of perjury. Sign in the presence of a Notary Public or other public official qualified by law to administer oaths. Applicant s Signature Notary Signature Date Date Commission Expires

7 The Commonwealth of Massachusetts Division of Professional Licensure Board of Registration of Veterinary Medicine 1000 Washington Street, Suite 710 Boston, MA Phone: (617) PROFESSIONAL AND ETHICAL REFERENCE FORM I,, hereby authorize, (applicant) (licensed veterinarian) to provide the Board of Registration in Veterinary Medicine, with all information of any kind which the veterinarian may deem relevant to my qualifications as an applicant. I hereby release and discharge the endorser from all claims arising out of the provision of such information. Date: Applicant s Signature: The remainder of this form is to be completed by the licensed veterinarian named above. Failure to do so will render this document invalid. Do not complete unless the above waiver is signed. This form must be signed by a Notary Public. 1. Name: 2. Address: 3. Tel. Number: 4. License Number: 5. State where licensed: 6. Relationship to the applicant (supervisor, professor, etc.): 7: Length of time known: From to (month/year) (month/year) 8. Indicate the setting(s) in which you have known the applicant, description of applicant s duties, and extent of your contact with applicant 9. Do you certify that the applicant is in good moral character? Yes No (continued)

8 10. Do you believe that this applicant conducts his/her activities in conformance with the Code of Ethics of the American Veterinary Medical Association (AVMA) Yes No If no, please explain 11. AFFIDAVIT I, the undersigned, being duly sworn do state under penalties of perjury that the answers given above are true and correct. I agree to provide any additional information requested by the Board. Date: Endorser s Signature Notary Name(print): Notary Signature: My Commission Expires:

9 The Commonwealth of Massachusetts Division of Professional Licensure Board of Registration of Veterinary Medicine 1000 Washington Street, Suite 710 Boston, MA Phone: (617) PROFESSIONAL AND ETHICAL REFERENCE FORM I,, hereby authorize, (applicant) (licensed veterinarian) to provide the Board of Registration in Veterinary Medicine, with all information of any kind which the veterinarian may deem relevant to my qualifications as an applicant. I hereby release and discharge the endorser from all claims arising out of the provision of such information. Date: Applicant s Signature: The remainder of this form is to be completed by the licensed veterinarian named above. Failure to do so will render this document invalid. Do not complete unless the above waiver is signed. This form must be signed by a Notary Public. 1. Name: 2. Address: 3. Tel. Number: 4. License Number: 5. State where licensed: 6. Relationship to the applicant (supervisor, professor, etc.): 7: Length of time known: From to (month/year) (month/year) 8. Indicate the setting(s) in which you have known the applicant, description of applicant s duties, and extent of your contact with applicant 9. Do you certify that the applicant is in good moral character? Yes No (continued)

10 10. Do you believe that this applicant conducts his/her activities in conformance with the Code of Ethics of the American Veterinary Medical Association (AVMA) Yes No If no, please explain 11. AFFIDAVIT I, the undersigned, being duly sworn do state under penalties of perjury that the answers given above are true and correct. I agree to provide any additional information requested by the Board. Date: Endorser s Signature Notary Name(print): Notary Signature: My Commission Expires:

11 The Commonwealth of Massachusetts Division of Professional Licensure 1000 Washington Street, Suite 710 Boston, MA (617) TEMPORARY PERMIT APPLICATION TO BE COMPLETED ONLY IF REQUESTING A TEMPORARY PERMIT TO PRACTICE GRADUATES OF NON-AVMA ACCREDITED VETERINARY SCHOOLS ONLY To be eligible for a temporary permit, a candidate must have passed the Board s Jurisprudence Examination and the North American Veterinary Licensing Examination (NAVLE) AND be within six (6) months of completing the ECFVG or PAVE programs. You must provide either an ECFVG or PAVE status report as proof that you meet this time requirement. A Board interview of the candidate and supervisor is required. If approved, a temporary permit is valid for six months, with the possibility of just one renewal for an additional six months. Under no circumstances will a temporary permit be valid over twelve months. Graduates of AVMA Accredited Veterinary Schools are not eligible for a temporary permit. To be completed by candidate and supervisor(s) Candidate Name Please Print Signature Date If the facility is a multi veterinarian practice, the Board suggests that all veterinarians that this candidate may be supervised by sign this form. Please the back of this form if additional space is needed. Supervisor Please Print License No. Signature Supervisor Please Print License No. Signature Supervisor Please Print License No. Signature Practice address & telephone number

12 Applicant s Checklist/Requirements for Licensure MANDATORY MY SOCIAL SECURITY NUMBER IS YOU MUST INCLUDE THIS WITH YOUR APPLICATION : - - Pursuant to G.L. c. 62C, s. 47A, the Division of Professional Licensure is required to obtain your social security number and forward it to the Department of Revenue. The Department of Revenue will use your social security number to ascertain whether you are in compliance with the tax laws of the Commonwealth." PLEASE CHECK EACH BOX: Completed application w/ photo NON-REFUNDABLE Fee of $ (check or money order payable to the Comm. of MA.) Completed Jurisprudence Exam (contact Board office at or leija.t.meadows@state.ma.us to obtain exam) Confirmation of degree. (If applying to take NAVLE, Item 8 on application certified statement from the Dean must be completed; When applying for licensure: Official sealed transcript of conferred degree or NOTARIZED copy of diploma must be submitted) Two completed Professional and Ethical Reference Forms from licensed veterinarians (must remain in sealed envelopes with back of envelope signed along the seal) (If applicable) Graduates from non-avma accredited Universities must provide documentation of enrollment in the Educational Commission for Foreign Veterinary Graduates (ECFVG) or the PAVE program. Certification from graduates of foreign veterinary schools (to sit for exam, the Board requires verification of enrollment in ECFVG or PAVE program and copy of veterinary diploma and transcript. For licensure, applicant must submit proof of completion of the ECFVG or PAVE programs) (If applicable) Exam scores from Veterinary Information Verifying Agency (VIVA) If you have/had a license in another state or foreign jurisdiction, sealed verification from each is required. IF APPLYING FOR TEMPORARY PERMIT Completed Temporary License Form with signatures of all supervisors.*** ***Upon receipt of the application, you will be notified of a scheduled interview with the Board. Board interviews are required in order to receive a temporary permit. At least one supervisor must accompany you to this interview. Interviews are held the second Thursday of each month, unless otherwise noted Should you have any questions about the application process, please contact Board Staff, at (617) or via Diane.m.Savickas@state.ma.us. Mail your materials to: Board of Registration in Veterinary Medicine 1000 Washington Street, Suite 710, Boston, MA